'Why didn't you write a not-for-cardiopulmonary resuscitation order?' Unexpected death or failure of process?

Impact of electronic medical records and COVID-19 on adult Goals-of-Care document completion and revision in hospitalised general medicine patients

BACKGROUND

Conversion from paper-based to electronic medical records (EMR) may affect the quality and timeliness of the completion of Goals-Of-Care (GOC) documents during hospital admissions, and the COVID-19 pandemic may have further impacted this.

AIMS

Determine the impact of EMR and COVID-19 on the proper completion of GOC forms, and the factors associated with inpatient changes in GOC.

METHODS

We conducted a cross-sectional study of adult general medicine admissions (Aug 2018-Sep 2020) at Dandenong Hospital (Victoria, Australia). We used interrupted time series to model the changes in the rates of proper GOC completion (adequate documented discussion, completed ≤2 days) after the introduction of EMR and arrival of COVID-19.

RESULTS

We included a total of 5147 patients. The pre-EMR GOC proper completion rate was 27.7% (overall completion, 86.5%). There was a decrease in the proper completion rate by 2.21% per month (95% CI: -2.83%, -1.58%) after EMR implementation despite an increase in overall completion rates (91.2%). The main reason for the negative trend was a decline in adequate documentation despite improvements in timeliness. COVID-19 arrival saw a reversal of this negative trend, with proper completion rates increasing by 2.25% per month (95% CI: 1.35%, 3.15%) compared to the EMR period, but also resulted in a higher proportion GOC changes within 2 days of admission.

CONCLUSION

EMR improved the timeliness and overall completion rates of GOC at the cost of a lower quality of documented discussion. COVID-19 reversed the negative trend in proper GOC completion but increased the number of early revisions. This article is protected by copyright. All rights reserved.

A simple ABCD score to stratify patients with respect to the probability of survival following in-hospital cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary resuscitation (CPR) is occurring more frequently at community hospitals but most patients undergoing CPR do not survive to discharge. Tools to predict CPR survival can be improved by the identification of high-yield clinical indicators.

OBJECTIVE

To identify variables associated with survival to discharge following in-hospital cardiac arrest.

METHODS

Retrospective cohort study of 463,530 hospital admissions from the Nationwide Inpatient Sample (2012-2016). The analysis includes adults (age ≥50) who underwent in-hospital CPR at US community hospitals.

RESULTS

Overall survival to discharge was 29.8% (95% CI: 29.5-30.1%). Age was the strongest predictor of survival and had greater prognostic value than the Charlson comorbidity index. Obesity was associated with improved survival (35.9%, 95% CI: 35.1-36.7%), whereas underweight patients had decreased survival (24.0%, 95% CI: 22.2-25.7%). Acute indicators of poor survival included hyperkalemia, hypercalcemia, and sepsis. We generated an ABCD index based upon four high-yield variables (age, body habitus, comorbidity, day of hospital admission). An ABCD score of 2 or less was a sensitive but non-specific predictor of post-CPR survival (96.8% sensitivity, 95% CI: 96.6-97.0), and those with extreme scores differed 3.8-fold with respect to post-CPR survival probability (46.0% versus 12.1%).

CONCLUSION

Age is the strongest predictor of post-CPR survival, but body habitus is also an important indicator that may currently be underutilized. Our results support improved post-CPR survival of obese patients, consistent with an 'obesity paradox'. The ABCD score provides an efficient means of risk-stratifying patients and can be calculated in less than 1 minute.

Patient factors affecting the proper completion of a goals-of-care form in a general medicine hospital admission

BACKGROUND

The goals-of-care (GOC) form is a resuscitation planning tool used to document informed decisions tailored for individual patients admitted to hospital. Proper and timely completion of the GOC form is essential for its effective utility.

AIMS

To identify patient factors which may affect the timely discussion and documentation of GOC forms in patients admitted under a general medicine unit.

METHODS

We performed a cross-sectional study of 2589 patients during 3093 admissions under the general medicine unit from January 2017 to July 2017 at Dandenong Hospital in Melbourne, Australia. The main outcome was the proper completion of GOC forms, defined as GOC completion within 48 h of admission and adequate discussion with the patient or substitute decision maker. We used logistic regression to determine the association between the main outcome and several patient-related independent variables.

RESULTS

A GOC form was completed in 66% of all admissions but only 35% were considered properly completed (timely and adequately discussed). In the general multivariable logistic regression model, the variables associated with proper completion of GOC forms were age (OR = 1.58), English as the main spoken language (OR = 1.43) and readmissions (OR = 1.27). In patients 75 years and older, additional factors associated with proper GOC completion were confusion on admission (OR = 1.31) and number of comorbidities (OR = 1.27).

CONCLUSIONS

The proper GOC form completion rates were suboptimal in general medicine admissions, particularly in younger patients with fewer comorbidities. Additional effort is needed to improve GOC completion in these patients and those whose primary spoken language is not English.

Advance care planning documentation strategies; goals-of-care as an alternative to not-for-resuscitation in medical and oncology patients. A pre-post controlled study on quantifiable outcomes

BACKGROUND

Health services in Tasmania, Victoria and now Western Australia are changing to goals-of-care (GOC) advance care planning (ACP) documentation strategies.

AIM

To compare the clinical impact of two different health department-sanctioned ACP documentation strategies.

METHODS

A non-blinded, pre-post, controlled study over two corresponding 6-month periods in 2016 and 2017 comparing the current discretional not-for-resuscitation (NFR) with a new, inclusive GOC strategy in two medical/oncology wards at a large private hospital. Main outcomes were the uptake of ACP forms per hospitalisation and the timing between hospital admission, ACP form completion and in-patient death. Secondary outcomes included utilisation of the rapid response team (RRT), palliative and critical care services.

RESULTS

In total, 650 NFR and 653 GOC patients underwent 1885 admissions (mean Charlson Comorbidity Index = 3.7). GOC patients had a higher uptake of ACP documentation (346 vs 150 ACP forms per 1000 admissions, P < 0.0001) and a higher proportion of ACP forms completed within the first 48 h of admission (58 vs 39%, P = 0.0002) but a higher incidence of altering the initial ACP level of care (P = 0.003). All other measures, including ACP documentation within 48 h of death (P = 0.50), activation of RRT (P = 0.73) and admission to critical (P = 0.62) or palliative (P = 0.81) care services, remained similar. GOC documentation was often incomplete, with most sub-sections left blank between 74 and 87% of occasions.

CONCLUSION

Despite an increased uptake of the GOC form, overall use remained low, written completion was poor, and most quantitative outcomes remained statistically unchanged. Further research is required before a wider GOC implementation can be supported in Australia's healthcare systems.